HomeMy WebLinkAbout01-04-13J 1505610140
REV-1500 EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisbur , PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 1 1 5 0
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 9 2 8 7 7 9 4 1 0 1 9 2 0 1 1 0 4 0 6 1 9 3 7
Decedent's Last Name
Suffix Decedent's First Name MI
B A I L E Y D E L O R E S
J
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS
1. Original Return
0 2. Supplemental Return ~ 3. Remainder Return (date of death
4. Limited Estate ~ prior to 12-13-82)
4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Livin Trust
(Attach Copy of Will) (Attach Copy of Trust) g 8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit date of death
( ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
Daytime Telephone Number
M A R C U S A- M c K N I G H T I I I 717 2 4 9 2 353
First line of address
I R W I N &
Second line of address
6 0 W E S T
City or Post Office
C A R L I S L E
P A 1 7 0 1 3
REGI~ER OF WILLS ltSi~'ONLY
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Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
TURE OF PERS RESP SIBLE FOR FI G RETURN
DATE
DDRESS I ~~- / '?i
65 BLUE PO.~.,D ROA
SI(~N~TI IRC f1C oo nrr~ ..
NEWVILLE
PA 1,7aLt1.
~+ ~ ~ inn i nr~1V RCrKtJtN IH I IVE
- DJTE/ 2
- --- ~
60 WEST POMFRET STREET CARLISLE
PLEASE USE ORIGINAL FORM ONLY P A 17 01, 3
Side 1 '~
~1
1505610140 1505610140
M c K N I G H T P- C.
P O M F R E T S T R E E T
State ZIP Code
J
1505610240
REV-1500 EX Decedent's Social Security Number
2 0 9 2 8 7 7 9 4
Decedent's Name: D E L O R E S J• B A I L E Y
RECAPITULATION
1.
...........................................
Real Estate (Schedule A) 1 • •
2.
......................................
Stocks and Bonds (Schedule B) 2' •
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .......................... 4.
1 6 2 2. 0 3
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. • . • • • 5•
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
^ Separate Billing Requested .......
7. ], 7 2 9 8 8 . 1 5
(Schedule G)
8 1 7 4 6 1 0. 1 8
8. Total Gross Assets (total Lines 1 through 7) ............ • • • • • • • • • • • •
9 1 6 1 8 5. 7 1
9. Funeral Expenses and Administrative Costs (Schedule H) .... .
.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .
10.
9
3
3.
4 4
11. Total Deductions (total Lines 9 and 10) ..............................
11.
.
1 7 1
1
9.
1 5
12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 1 5 7 4 9 1 . 0 3
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13
an election to tax has not been made (Schedule J) .... • • • • • • • • • .
14. Net Value Subject to Tax (Line 12 minus Line 13) ..
•,..
... • • •
...
...
...14.
1 5 7 4 9 1.
0
3
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 ~~ ~ 0 15 O. 0 0
(a)(1.2) X .0
16. Amount of Line 14 taxable 1 5 7 4 9 1 0 3 16. 7 0 8 7' 1 0
at lineal rate X .045
17. Amount of Line 14 taxable 0 ~ ~ ~ 17 ~ • 0 0
at sibling rate X .12
18. Amount of Line 14 taxable ~ ~ ~ 0 18. 0 • 0 0
at collateral rate X .15
19.
...................................
19. TAX DUE .................. .
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505610240
Side 2
7 0 8 7. 1 0
0
1505610240 J
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
DELORES J. BAILEY 21 11 1150
Decedent's Name Page 1 File Number
Correspondents
Name
M A R C U S A
First line of address
I R W I N &
Second line of address
6 0 W E S T
City or Post Office
C A R L I S L E
Correspondent's a-mail address:
Daytime Telephone Number
M c K N I G H T I I I 7 1 7 2 4 9 2 3 5 3
M c K N I G H T P C.
P O M F R E T S T R E E T
State ZIP Code
P A 1 7 0 1 3
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my Knowieage ano Feuer,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIB E FOR ~I G RETURN DATE
i
ADDRESS
F~ FIrKFS ROAD NEWVILLE PA 17241
Name Daytime Telephone Number
MA R C U S A Mc K N I GH T I I I 7 1 7 2 4 9 2 3 5 3
First line of address
I R W I N & M c K N I G H T P C.
Second line of address
6 0 W E S T P O M F R E T S T R E E T
City or Post Office State ZIP Code
C A R L I S L E P A 1 7 0 1 3
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESI~{JNSIBLE FOR FILING RETURN DATE
/' _ 2 - [ ~
,, ~
ADDRESS
2536 RITNER HWY LOT 105 CARLISLE PA 17015
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
DELORES J. BAILEY
STREET ADDRESS
429 DOGWOOD CT._
CITY
CARLISLE
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments ~ 10,595.50
A. Prior Payments
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
File Number
21 11 1150
ZIP
STATE
PA ~ 17015
(1) 7,087.10
Total Credits (A + B) (2) 10, 595.50
(3)
(5)
(4) 3, 508.40
0.00
Make check payable to: REGISTER OF WILLS, AGENT
PEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
Yes
^
No
a. retain the use or income of the property transferred; ..........~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~" ~"~
^
b. retain the right to designate who shall use the property transferred or its income; ........... ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
^ X
c. retain a reversionary interest; or ........................................................................................... .....
^
d. receive the promise for life of either payments, benefits or care? .............~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
..... ~
^
without receiving adequate consideration? .................................................................................
3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? ... .
...... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
~
^
contains a beneficiary designation? ............................................................................................ ......
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
th on or after Jul 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
For dates of dea Y
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate im osed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
p
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX+ (11-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER:
ESTATE OF:
DELORES J. BAILEY 21 11 1150
Include the proceeds of litigation and the date the proceeds were received by the estate.
eu .,~,...orr" inint~~ owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
~, F&M TRUST -CHECKING ACCOUNT #0003632369
2. ~ PERSONAL PROPERTY
VALUE AT DATE
OF DEATH
622.03
1,000.00
TOTAL (Also enter on Line 5, Recapitulation) I $ 1,622.03
If more space is needed, insert additional sheets of paper of the same size
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
FILE NUMBER
ESTATE OF
DELORES J. BAILEY 21 11 1150
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 22, 393.05
~. NATIONAL WESTERN LIFE INSURANCE COMPANY 22,393.05 100.00
ANNUITY CONTRACT #01001128736
2. NATIONAL WESTERN LIFE INSURANCE COMPANY
41,604.63 100.00
41,604.63
ANNUITY CONTRACT #0101245294
3. NATIONAL WESTERN LIFE INSURANCE COMPANY
7,314.07 100.00
7,314.07
ANNUITY CONTRACT #0101152905
4. NATIONAL WESTERN LIFE INSURANCE COMPANY
7,315.52 100.00
7,315.52
ANNUITY CONTRACT #010011529006
5. NATIONAL WESTERN LIFE INSURANCE COMPANY 43,849.54 100.00
43, 849.54
ANNUITY CONTRACT #01011529008
6. LIFE INSURANCE COMPANY OF THE SOUTHWEST/LSW 31,511.55 100.00
31, 511.55
ANNUITY CONTRACT #681235X
7. LIFE INSURANCE COMPANY OF THE SOUTHWEST/LSW 18,999.79 100.00
18,999.79
ANNUITY CONTRACT #709637X
8. SHENANDOAH LIFE INSURANCE COMPANY
0.00 0.00
0.00
LIFE INSURANCE #002106853
REMOVED FROM RETURN
BENEFICIARIES ON ABOVE ANNUITIES:
KIMBERLY PAULUS
ALECIA BAGROSKY
GWENDOLYN BARRICK
TOTAL (Also enter on Line 7, Recapitulation) $ 172 988.15
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF
DELORES J. BAILEY 21 11 1150
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION
NUMBER
A. FUNERAL EXPENSES:
~. EWING BROTHERS FUNERAL HOME, INC.
2. GREEN SPRINGS CHURCH OF GOD -CHURCH/PASTOR/ORGANIST
AMOUNT
162.34
300.00
g, ADMINISTRATIVE COSTS:
~ , Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2,500.00
2 Attorney Fees: IRWIN & McKNIGHT, P.C.
3 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
107.50
4. Probate Fees: REGISTER OF WILLS
5 Accountant Fees:
6
Tax Return PreparerFees: P
L
O 500.00
. IDUC ARY TAX RETURN
F
NS & FINA
INCOME TAX RETUR
30.00
7 REGISTER OF WILLS -FILING FEE 1,948.59
,
g. LITIGATION FEES -SEE ATTACHED
ATTORNEY FEES PRIOR TO DATE OF DEATH 312.50
g IRWIN & McKNIGHT, P.C., - 75.00
,
10. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 210.78
11. THE SENTINEL -ESTATE NOTICE 35.00
12 NOTARY FEES 10,000.00
.
13 MINDY DEATRICK -LITIGATION PAYOUT 4.00
.
14. REGISTER OF WILLS -SHORT CERTIFICATE
TOTAL (Also enter on Line 9, Recapitulation) $ 16,185.71
If more space is needed, use additional sheets of paper of the same size
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
ESTATE OF
DELORES J. BAILEY 21 11 1150
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
NUMBER
473.00
1. INTERNAL REVENUE SERVICE -INCOME TAXES
2~~.0~
2, PA DEPARTMENT OF REVENUE -INCOME TAXES
65.18
3. CARLISLE REGIONAL MEDICAL CENTER -MEDICAL
49.45
4. PP&L -ELECTRIC
34.00
5. SOUTH MIDDLETON TOWNSHIP MUNICIPAL - WATERISEWER
34.81
6. SPRINT-TELEPHONE
TOTAL (Also enter on Line 10, Recapitulation) $ 933.44
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
DELORES J. BAILEY
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
I. Sec. 9116 (a) (1.2).]
1, GWENDOLYN A. BARRICK
61 FICKES ROAD
NEWVILLE, PA 17241
2. ALECIA K. BAGROSKY
65 BLUE POND ROAD
NEWVILLE, PA 17241
3. KIMBERLY D. PAULUS
2536 RITNER HIGHWAY LOT 105
CARLISLE, PA 17015
FILE NUMBER:
21 11 1150
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Lineal
Lineal
Lineal
AMOUNT OR SHARE
OF ESTATE
52,497.01
1/3 REMAINDER
52,497.01
1/3 REMAINDER
52,497.01
1/3 REMAINDER
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size,
. ~~ SHENANDOAH LIFE
INSURANCE COMPANY
November 7, 2011
ALECIA K BAGROSKY
PO BOX 226
MT HOLLY PA 17065
RE: DECOKES J BAILE`~
POLICY: 002106853
CLAIM: 0000042556
Dear Ms. Bagrosky:
This letter will acknowledge Shenandoah Life Insurance Company's receipt of your claim to the
benefit of policy 002106853 insuring the life of Delores J. Bailey.
Please be advised that Shenandoah Life Insurance Company has received a competing claim for
the proceeds of Ms. Bailey's life insurance policy. Mindy Deatrick has indicated her intent to
challenge the distribution of proceeds on Ms. Bailey's policy.
Given the information as currently presented, Shenandoah Life cannot distribute the policy
proceeds at this time. If you have any information you would like us to consider during our
review of this matter, you are requested to provide such information/documentation to us within
10 days of this letter.
Thank you for your assistance regarding this matter.
Sincerely,
Shirley W. Simmons, ACS
Claims Examiner
^ fax: 540 857-5957 • www.shenlife.coil~
P.O. Box 12847 • ROANOKE, VIRGINIA 24029 • (800) 848-543 • ( )
~~ SHENANDOAH LIFE
INSURANCE COMPANY
November 7, 2011
GVVENDOLYN A BARRICK
61 FICKES RD
NEWVILLE PA 17241
RE: DELORES J BAILEY
POLICY: 002106853
CLAIM: 0000042556
Dear Ms. Barrick:
This letter will acknowledge Shenandoah Life Insurance Company's receipt of your claim to the
benefit of policy 002106853 insuring the life of Delores J. Bailey.
Please be advised that Shenandoah Life Insurance Company has received a competing claimtf~o
the proceeds of Ms. Bailey's life insurance policy. Mindy Deatrick has indicated her mten
challenge the distribution of proceeds on Ms. Bailey's policy.
Given the information as currently presented, Shenandoah Life cannot distribute the policy
roceeds at this time. If you have any information you would like us to consider during our
P
review of this matter, you are requested to provide such information/documentation to us within
10 days of this letter.
Thank you for your assistance regarding this matter.
Sincerely,
Shirley W. Simmons, ACS
Claims Examiner
• 540 985-4400 • fax: (540) 857-5956 • www.shenlife.com
P.O. BOX 12847 • ROANOKE, VIRGINIA 24029
~~ SHENANDOAH LIFE
INSURANCE COMPANY
November 7, 2011
KIMBERLY D PAULUS
2536 RITNEY HWY LOT 105
CARLISLE PA 17015
RE: DECOKES J BAILEY
POLICY: 002106853
CLAIM: 0000042556
Dear Ms. Paulus:
This letter will acknowledge Shenandoah Life Insurance Company's receipt of your claim to the
benefit of policy 002106853 insuring the life of Delores J. Bailey.
Please be advised that Shenandoah Life Insurance Company has received a competing claim for
the proceeds of Ms. Bailey's life insurance policy. Mindy Deatrick has indicated her intent to
challenge the distribution of proceeds on Ms. Bailey's policy.
Given the information as currently presented, Shenandoah Life cannot distribute the policy
proceeds at this time. If you have any information you would like us to consider during our
review of this matter, you are requested to provide such information/documentation to us within
10 days of this letter.
Thank you for your assistance regarding this matter.
Sincerely,
Shirley W. Simmons, ACS
Claims Examiner
• 800 848-5433 • fax: (540) 857-5956 • www.shenlife.com
P.O. BOx 12847 • ROANOKE, VIRGINIA 24029 ( )
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